Gastroparesis is a condition in which stomach motility is reduced due to nerve injury and/or muscle dysfunction. Due to this reduced motility, the stomach is unable to properly empty itself, leading to symptoms that may include nausea, vomiting, bloating, heartburn, and feeling full quickly when eating. This condition may also result in chronic abdominal pain, and decreased appetite leading to weight loss. In patients with diabetes, poor blood glucose control is of concern as well. Most cases of gastroparesis are idiopathic in nature, but diabetes and some medications have been known to cause this condition as well. In this post, we will discuss gastroparesis treatment.

It should be noted that the first-line treatment for gastroparesis includes resuscitation of fluids and electrolytes, and glycemic control in patients with diabetes. Change in diet is also recommended. This would include eating smaller, more frequent meals throughout the day, avoiding high fat and high fiber foods, and eating liquid or low residue meals that are easier to digest. 

As for medication treatment for gastroparesis, this may include prokinetic agents, antiemetic agents, certain antidepressants, and pain medications.

• Prokinetic agents may improve nausea, vomiting and bloating due to gastroparesis. 
  • Metoclopramide (podcast episode): first-line agent for gastroparesis treatment, should be administered at the lowest effective dose.
  • Erythromycin: IV formulation may be used in patients who are hospitalized. The oral formulation may also be used, though it is not a long-term option due to tachyphylaxis occurring within 4 weeks of use.
  • Domperidone (not available in the US): may improve symptoms and gastric emptying, as well as reduce hospitalization in patients who have diabetes and gastroparesis. 
• Antiemetic agents are used to help control nausea and vomiting symptoms.
  • Ondansetron 
  • Prochlorperazine 
  • Promethazine
  • Diphenhydramine 
• Antidepressants
  • Mirtazapine: appetite stimulation and slight antiemetic effects have shown to be beneficial in those with gastroparesis. 
  • Nortriptyline/amitriptyline: used in low doses may improve some symptoms, especially dyspepsia.
• Pain medications 
  • More studies are needed for the most effective pain medication for gastroparesis, although narcotic pain medications are not recommended for this condition 

Metoclopramide and erythromycin are the two most commonly used agents for gastroparesis that I’ve seen in practice. There are numerous clinical pearls associated with each of these medications that you should be familiar with. Here’s a metoclopramide case scenario that demonstrates a major concern with the medication. Metoclopramide should be used cautiously because of its dopamine-blocking action and potential to contribute to inappropriate movement-type adverse effects. Erythromycin makes me a little nervous because of its numerous CYP3A4 drug interactions and QTc prolongation potential. For more details on these agents, you have to check out these two awesome podcast episodes.

Metoclopramide Pharmacology Podcast

Erythromycin Pharmacology Podcast

This article was written by Krista Olson, PharmD Candidate in collaboration with Eric Christianson, PharmD, BCPS, BCGP

References

1. U.S. Department of Health and Human Services. Treatment for gastroparesis. National Institute of Diabetes and Digestive and Kidney Diseases. 2018. Available at https://www.niddk.nih.gov/health-information/digestive-diseases/gastroparesis/treatment 
2. Gastroparesis. DynaMed. EBSCO Industries, Inc., Birmingham, Alabama, USA. Available at https://www.dynamed.com/condition/gastroparesis#GUID-DB9B22A6-1334-43EF-9DFA-63B9D94684DF.
3. Gastroparesis: Symptoms, causes, diagnosis & treatment. Cleveland Clinic. 2018. Available at https://my.clevelandclinic.org/health/diseases/15522-gastroparesis 
4. Gastroparesis. In: American College of Gastroenterology. 2022. Available at https://gi.org/topics/gastroparesis/. 
5. Bielefeldt, K. (2012). Gastroparesis: concepts, controversies, and challenges. Scientifica, 2012. Available at https://www.hindawi.com/journals/scientifica/2012/424802/